Ultrasonic Cavitation /Laser Lipo *Consent Agreement
*Pre-Post Treatment Agreement
Please read before booking your Ultrasonic Cavitation or Laser Lipo Treatment(s).
We will email you the agreements to sign and bring in with you, before your appointment.
If you have any questions, please contact me.
615-414-7939 (Please text)
ULTRASONIC CAVITATION / LASER LIPO PATIENT CONSENT
This Form will be emailed to you and must be completely filled out, signed by the patient, bring in with you on the first appointment, and accepted by The Gua Sha Facial Co. before any treatments will be performed.
Ultrasonic Cavitation, also known as Cavi Lipo, as well as Laser Light Lipo are technologies for breakdown of the fat deposits. These procedures do not involve invasive surgery - there is no need for anesthesia, hospital stay and no down time. They provide a non-invasive method to break down stubborn fat deposits that never seem to disappear no matter what your diet is or how hard you exercise. The most problematic body areas are abdomen, flanks (love handles), inner thighs, buttocks, inner knees, under chin and upper arm.
Appointments are usually scheduled one treatment per week. In order to ensure maximum results, it is necessary to follow the recommended treatment schedule. The total number of treatments will vary between individuals. On occasion, there are patients that do not respond to treatments.
I have read, agree to, and understand the following:
I understand the nature, goals, limitations and possible complications of this procedure and have discussed alternative forms of treatment. I have had the opportunity to ask questions about the procedure, as well as any limitations, complications and/or side effects.
The goal of any treatment, as in any cosmetic procedure, is improvement, not perfection, and results may not be perfect due to any genetic, hormonal, nutritional, or topical applications interference or an impact of unpredictable reactions.
Allergic Reactions: In rare cases, allergies to tape, preservatives used in cosmetics, topical preparations, etc. have been reported. Systemic reactions (which are more serious) may result from prescription medicines.
·Compliance with the aftercare guidelines is crucial.
Occasionally, unforeseen mechanical problems may/could occur with a machine and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.
Do not accept advice from anyone not directly responsible for your post care. Suggestions from friends may be sincere, but are often not helpful or can be innocently harmful. If you have questions or concerns, please contact your Cavi/Laser Lipo Practitioner.
I have read and understand all of the above. I have asked any and all questions that I have regarding the procedure of laser light lipo/cavi lipo/ultrasonic cavitation, pre-treatment and post-treatment. I was given written instructions for post-treatment care at home. I understand completely and will take full responsibility for post-treatment care.
All of the treatment fees have been discussed with me and I understand them completely.
My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release Darlene McDowell and all related staff from all liabilities associated with the above-indicated procedure.
By signing this form, I am giving Darlene McDowell/The Gua Sha Facial, permission to treat me, and I understand all symptoms and side effects that may occur during or after treatments, thereby releasing Darlene McDowell/The Gua Sha Facial Co. and all related staff of all liability regarding these issues.
Should you have any concerns or questions, please do not hesitate to call our office. Our main goal is client satisfaction. That is why it is VERY important to educate our clients so they will fully understand the procedures of Laser Lipo/ Ultrasonic Cavitation and have trust, confidence and cooperation in their decision.
All clients MUST sign this Consent Form indicating that they have read all of the pre- and post-treatment instructions. The consent form is an agreement with the client that he/she is agreeing to be treated and that the client fully understands all pre- and post-treatment instructions as well as possible symptoms and/or side effects and skin reactions that may occur due to treatment. These symptoms and side effects include: diarrhea, headaches, toothaches if client has metal teeth fillings, bruising, ringing in the ears, kidney failure (if client has a kidney disease) liver failure (e.g. fatty infiltration of the liver or if client has a liver disease), carrying a pacemaker or other electronic devices, pregnancy, lactation, hypertriglyceridemia, or hypercholesterolemia. These symptoms and side effects are normal and cannot be predicted. All side effects vary with each individual. That is why it is important to discuss any medical history.
I understand that the treatments are NOT appropriate for the following reasons:
Presence of metallic prosthesis
Acute inflammatory processes
Tumors or cancer
Proximity of the organs and the bone marrow
Pace maker, high blood pressure or heart problems
Pregnancy / breastfeeding
Metal plates in your body
Active infections, hives, herpetic lesions, or cold sores
Herpes simplex virus infections (mouth sores)
Extreme sensitivity or allergic reactions in the treated area
Kidney damage, liver damage or diseases
Hemorrhagic disease, clotting or bleeding
Medical plastic parts or parts with meal inside
Abnormal immune system
Numb or insensitive to heat
If I mislead the technician/practitioner for any of the reasons mentioned above, by signing below I fully understand and take responsibility for the post-treatment consequences.
Initial Please. I cannot perform any treatment without initials on all statements below.
I have provided my past and current medical history and medications.
I am not pregnant or nursing.
I have been given the opportunity to ask questions about the procedure. My questions have been answered and I understand the information given to me.
Contraindications to the performance of this procedure have been discussed in detail with me.
I recognize that laser lipo/ ultrasonic cavitation is not an exact science and acknowledge that no guarantees have been made to me concerning the results of such procedures.
I have read and understood all information presented to me before signing this consent form.
I hereby release Darlene McDowell, the Gua Sha Facial Co. and all related staff from all liabilities associated with the above- indicated procedure.
By signing this form, I am giving Darlene McDowell/The Gua Sha Facial Co. permission to treat me with Ultrasonic Cavitation/Cavi Lipo/Laser Light Lipo and I understand all symptoms and side effects that may occur during or after treatments, thereby releasing Darlene McDowell/The Gua Sha Facial Co. of any liability whatsoever regarding these issues.
24 HOURS CANCELLATION POLICY
Confirmation of your appointments is a courtesy email/text from us, not an obligation. It is the client’s full responsibility to keep track of his/her scheduled appointments. If client fails to notify of appointment cancellation at least 24 hours in advance, the no-show will be counted as a used treatment of the client’s package deal or $40.00 fees must be paid to accommodate the technician/practitioner’s time. For any credit card payments cancelled, a 20% surcharge and merchant fee will be deducted for any refunds made 7 (seven) days after original transaction.
PACKAGE REFUND POLICY. By signing this No Refund Policy, I am agreeing that any service(s), service package(s), gift certificate(s), and/or retail product(s) I purchase at The Gua Sha Facial is a final sale. I understand any and all services(s), service package(s), gift certificate(s), and/or retail product(s) purchased will not be refunded or issued a credit. I also understand that if I decide to cancel or postpone any service(s), service package(s), gift certificate(s), and/or retail product(s), I will forfeit all monies paid; including any deposits and/or payments I have already paid.
I fully understand this consent form / agreement and I acknowledge being given a copy of this Agreement at the time it was signed.
THIS FORM MUST BE COMPLETED & SIGNED BEFORE RECEIVING ANY TREATMENTS.
MUST BE 18 YRS. OR OLDER FOR ANY TREATMENTS TO BE PERFORMED. NO EXCEPTIONS.
PRE and POST TREATMENT AGREEMENT for:
Ultrasonic Cavitation (Cavi Lipo) & Laser Lipo
You may NOT be able to participate in the Cavi/Laser Lipo Ultrasonic Cavitation Program if you have the following contraindications or precautions:
• Pregnant or breast-feeding, or undergoing fertility treatments
• Heart disease, High or Low blood pressure, Circulation problems, Arrhythmias, irregular heart rhythm
• Pacemaker or metal hardware
• Compromised Immune System
• Liver or Kidney disease
• Using anti-inflammatory, anti-coagulants, antibiotics
• Skin problems
• Under the age of 18
Always seek medical advice before starting, changing or terminating any medical treatment or daily routine such as exercise, diet or water intake.
Before your Treatment
The first session will include a consultation to determine if your body will respond appropriately. Total session time is generally 45 minutes to one hour in length for one area.
Drink at least 2.0 liters (8 glasses of 8 oz. of liquid) of water daily, especially the day before and on the treatment day. Should you have any condition of the heart or kidney or are on diuretics or any medication that affects the kidney, heart, liver or lymphatic system, please check with your physician regarding the proper water intake for you.
Keep a balanced diet and avoid fatty foods, at least 3 days before treatment.
Please wear appropriate clothing to your appointment. Comfortable clothing.
After your Treatment
** Essentially, Ultrasound Fat Cavitation/ Laser Lipo will destabilize and break down fat into carbohydrates and waste material. That is why cardiovascular exercise and water are vital.
Cardio afterwards serves two purposes; to burn off the released carbohydrates, and to encourage the contraction and expansion of lymphatic vessels to channel out waste.
Meanwhile, the water acts to thin that waste and to hasten its removal from the body through the urine.
Continue with brisk to moderate exercise following your treatments. This helps regulate the lymphatic system, tone skin and many other incredible benefits, which also includes a reduction in stress.
Follow these simple rules to maximize results:
A balanced diet is the best diet. Often clients will need to reduce intake of simple carbohydrates so they do not compete with those produced by the treatment. Simple carbohydrates include sugar, bread, buns, most sweet fruit, white rice, and pasta. Brown rice, nuts, unprocessed pocket breads, and vegetables are fine.
Consume two liters (8/8 oz) of water each day, and even more with exercise.
Should you have any condition of the heart or kidney or are on diuretics or any medication that affects the kidney, heart, liver or lymphatic system, please check with your physician regarding the proper water intake for you.
Avoid caffeine and more importantly, alcohol for 48 hours after your treatment, they compete with your liver. Stay away from carbonated water and no soda!
Let us know if you begin any new medications, including the pill, topical creams, and natural supplements, or if you are beginning to plan for having a child, or if you are diagnosed with any disease, syndrome, or skin disorder, which you have not previously informed us about.
Follow any advice you may be given during your treatment. Every person is different. We are trained professionals and will tailor each treatment to suit you and answer any questions you may have.
Diaphragmatic breathing - Conscious, diaphragmatic breathing is like a massage for your internal organs! It also encourages lymph flow. Sit upright in a comfortable chair or lie on your bed with your knees slightly bent. Rest your hands on your ribs. Take deep breaths to relax. As you breathe in, direct the air down to your tummy (abdomen), which you will feel rising under your hands. (Imagine that there is a balloon in your stomach: Inhale– fill up the balloon in your belly) Breathe out slowly by ‘sighing’ the air out. While breathing out, let your abdomen relax in again. (Exhale– deflate the balloon.) Do the deep breathing exercises five times. Have a short rest before getting up to avoid feeling dizzy. Start out very slowly and only try a few breaths at a time, but practice a few times a day. Breathing will change naturally because of structural manipulation.
Do NOT take a hot shower (warm is alright), spa or sauna straight after treatment.
If you experience any mild swelling or redness in the treated area, please contact us.
Please keep the following statements in mind throughout our Cavi / Laser Lipo Program.
Combining a balanced diet and regular exercise with the Cavi / Laser Lipo Treatments are the most efficient ways to eliminate and keep away cellulite and fat cells from forming.
Please be aware that results vary across individuals, but as your professional technician/practitioners, we are trained to help you get the best results from your treatment.
If you are uncomfortable at any stage of the treatment, please make your practitioner aware immediately.
Although our Cavi Lipo/ Laser Lipo Treatments may result in weight loss and fat reduction in conjunction with exercise and proper nutrition, this program is not for weight loss.
This treatment is designed for body shaping and to reduce stubborn fatty areas that don’t seem to budge.
Do not expect this treatment to strip away huge layers of fat in a single session. Results can sometimes be noticed after the first treatment, with more improvement noticed within a few days. Desired results may be achieved within 6 to 12 sessions depending on your body type and your desire goals. Please keep in mind that every body is different and many factors contribute to the production of fat and cellulite.
I have read and understand the Pre and Post Agreement for my treatment.
I agree to the following conditions of the Cavi Lipo/Laser Lipo Program:
• To keep all my Laser Lipo / Cavi Lipo / Ultrasonic Cavitation appointments. (of course unless an emergency arises.)
• To maintain normal eating habits.
• I will report any significant health issues that may occur during the course of the program.
• I agree to abide by all the guidelines in the Pre and Post Treatment Instructions.
• I have received pre and post care instructions for the Cavi Lipo Treatment program.
• I understand that Darlene McDowell/The Gua Sha Facial has a strict 24 hour cancellation policy, and if I am to cancel an appointment within 24 hours of the scheduled time, I am responsible for the paying the full amount of the session. (exception for emergencies, to be determined)
• I am aware and agree to the above terms and conditions.
• I am aware that every safety measure will be undertaken by the practitioner/technician and staff and may include refusal of my treatment if deemed unsafe.
You must be able to abide with the Ultra Cavitation or Laser Lipo Consent form, as well as the Pre/Post Cavi/Laser Lipo Agreement.
(We will send these agreements with a Personal Medical History form) You will need to sign and bring all forms with you on your first appointment.
Any questions, please contact: Darlene McDowell
You may also text Darlene McDowell at 615-414-7939.
If you are ready to book your Ultrasound Cavitation or Laser Lipo Appointment
Click Here > CAVI/LIPO APPOINTNMENT